Barriers to Universal Prescribing of Antiretroviral Therapy by HIV Care Providers in the United States, 2013-2014

Coordinating Care for People With HIV Who Have Lower Incomes and Alternative Sources of Health Care Coverage

ABSTRACT

As people with HIV increasingly access affordable health care coverage-enabling them to obtain medical care from private providers-understanding how they use the Ryan White HIV/AIDS Program (RWHAP), and their unmet health care needs, can enhance their overall care. We analyzed RWHAP client-level data and interviewed staff and clients at 29 provider organizations to identify trends in health care coverage and service use for clients who received medical care from private providers. The RWHAP helps cover the cost of premiums and copays for these clients and provides medical and support services that help them stay engaged in care and virally suppressed. The RWHAP plays an important role in HIV care and treatment for clients with health care coverage. The growing number of people who receive a combination of services from RWHAP providers and private providers offers opportunities for greater care coordination through communication and data sharing between these settings.

The Association Of HIV With Health Care Spending And Use Among Medicare Beneficiaries

An increasingly older population of people with HIV raises concerns about how HIV may influence care for Medicare patients. We therefore sought to determine the extent to which HIV influences additional spending on and use of mental health and medical care among Medicare beneficiaries and, importantly, whether treatment with antiretroviral therapy may reduce this additional spending. Using 2016 Medicare claims, we compared risk-adjusted spending and utilization for Medicare beneficiaries with and without HIV, as well as subgroups of people receiving antiretroviral therapy (ART). Compared to beneficiaries without HIV, those with HIV receiving ART incurred 220.6 percent more spending, mostly driven by ART spending, whereas those with HIV not receiving ART incurred 95.4 percent more spending. Among beneficiaries with HIV, those receiving more months of ART had lower spending on treatment for other chronic conditions relative to those receiving fewer months of ART in a dose-response manner. Beneficiaries with HIV not receiving ART incurred the highest spending related to infections, mental health disorders, and other medical conditions compared to beneficiaries in other HIV subgroups receiving ART for various numbers of months. Our findings suggest that ART may be associated with Medicare Parts A and B savings, but ART adherence and the high prices of HIV drugs in Part D need to be addressed.

Gaps in the continuum of care among people living with HIV in Afghanistan

BACKGROUND

Afghanistan adopted a "test and treat" strategy for all people living with HIV (PLWH) in 2016. In this study, we presented demographic and clinical characteristics of all people diagnosed between 2013 and 2019 and evaluated progress towards 90-90-90 UNAIDS targets and identified program gaps among PLWH in Afghanistan diagnosed in 2018.

METHODS

We used clinical, behavioral, and demographic data from national HIV surveillance for 1394 patients diagnosed from 2013 through 2019. We also tracked 184 patients diagnosed with HIV in 2018 over 15 months to assess their enrollment in care, antiretroviral therapy (ART) initiation, retention on ART, and viral suppression.

RESULTS

Of 1394 patients diagnosed from 2013 through 2019, 76.0% were male, 73.7% were older than 24 years, and 33.4% acquired HIV through heterosexual sex. Of the 184 patients diagnosed in 2018, 94.6% were enrolled in care, 88.6% received ART, 84.2% were retained on ART for at least 12 months, and 33.7% received a viral load test. Of those with a viral load test, 74.2% were virally suppressed. Patients who were 35-44 years old (52.0%, p-value .001), acquired HIV through unsafe injection (62.5%, p-value .413), were co-infected with hepatitis C virus (HCV) (60.0%, p-value .449), and with CD4 > 500 at diagnosis (64.7%, p-value .294) were less likely to be virally suppressed 12 months after diagnosis.

CONCLUSION

Nearly 95% of people diagnosed with HIV in Afghanistan in 2018 were linked to care and nearly 90% were on ART. Viral testing and viral suppression remain low with notable disparities for middle-aged patients, and possibly for those who injected drugs. Addressing barriers to HIV programs in Afghanistan, particularly for people who inject drugs (PWID), are urgently needed to reach the 90-90-90 global targets. Surveillance data on the number of people with undiagnosed HIV is needed to assess the first 90 target.

Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder

BACKGROUND

Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation.

METHODS

CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression.

RESULTS

Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001).

CONCLUSIONS

Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.

Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States

BACKGROUND

Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States.

METHODS

We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences.

RESULTS

We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001).

CONCLUSIONS

Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.

Long-Term Mortality after Histoplasma Infection in People with HIV

Histoplasmosis is a common opportunistic infection in people with HIV (PWH); however, no study has looked at factors associated with the long-term mortality of histoplasmosis in PWH. We conducted a single-center retrospective study on the long-term mortality of PWH diagnosed with histoplasmosis between 2002 and 2017. Patients were categorized into three groups based on length of survival after diagnosis: early mortality (death < 90 days), late mortality (death ≥ 90 days), and long-term survivors. Patients diagnosed during or after 2008 were considered part of the modern antiretroviral therapy (ART) era. Insurance type (private vs. public) was a surrogate indicator of socioeconomic status. Out of 54 PWH infected with histoplasmosis, overall mortality was 37%; 14.8% early mortality and 22.2% late mortality. There was no statistically significant difference in survival based on the availability of modern ART (p = 0.60). Insurance status reached statistical significance with 38% of survivors having private insurance versus only 8% having private insurance in the late mortality group (p = 0.05). High mortality persists despite the advent of modern ART, implicating a contribution from social determinants of health, such as private insurance. Larger studies are needed to elucidate the role of these factors in the mortality of PWH.

HIV Treatment Knowledge in the Context of "Treatment as Prevention" (TasP)

According to 2012 universal ART guidelines, as part of "treatment as prevention" (TasP), all people living with HIV (PLWH) should immediately initiate antiretroviral therapy post-diagnosis to facilitate viral suppression. PLWH who are virally suppressed have no risk of sexually transmitting HIV. This study used descriptive analysis of quantitative data (N = 99) and thematic analysis of qualitative interviews (n = 36) to compare participants recruited from a hospital-based detoxification (detox) unit, largely diagnosed with HIV pre-2012 (n = 63) vs. those recruited from public, urban sexual health clinics (SHCs), mainly diagnosed in 2012 or later (n = 36). Detox participants were significantly more knowledgeable than SHC participants about HIV treatment, except regarding TasP. SHC participants' desire for rapid linkage to care and ART initiation was in line with 2012 universal ART guidelines and TasP messaging regarding viral suppression. More targeted messaging to PLWH pre-2012 could ensure that all PLWH benefit from scientific advances in HIV treatment.

Barriers and Facilitators for Antiretroviral Treatment Adherence Among HIV-Positive African American and Latino Men Who Have Sex With Men

Some Black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not take antiretroviral therapy (ART). We conducted semistructured interviews with 84 adult, Black/African American and Hispanic/Latino MSM with HIV to understand ART barriers and facilitators. We used chi-square statistics to identify factors associated with ART use (p ≤ .05), and selected illustrative quotes. Over half (51.2%) said they followed their doctor's instructions; however, only 27.4% reported consistently taking ART. Some men delayed ART until overcoming diagnosis denial or becoming very sick. ART use was facilitated by encouragement from others, treatment plans, side effect management, lab test improvements, pill-taking reminders, and convenient care facilities that provide "one-stop shop" services. Men were more likely to take ART when having providers who communicated effectively and were perceived to treat them with respect. Healthcare personnel can use our findings to strengthen services for MSM of color.

Sustaining the HIV care provider workforce: Medical Monitoring Project HIV Provider Survey, 2013-2014

OBJECTIVE

To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non-ID physicians, nurse practitioners (NPs), and physician assistants (PAs).

DATA SOURCES

Medical Monitoring Project 2013-2014 HIV Provider Survey.

STUDY DESIGN

Population-based complex sample survey.

DATA COLLECTION/ANALYSIS METHODS

We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao-Scott chi-square tests and logistic regression used to compare characteristics of ID physicians with each other provider type.

PRINCIPAL FINDINGS

The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non-ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non-ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non-ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent).

CONCLUSION

Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high-quality workforce.

The Influence of Housing Status on the HIV Continuum of Care: Results From a Multisite Study of Patient Navigation Models to Build a Medical Home for People Living With HIV Experiencing Homelessness

Objectives. To examine the effect of patient navigation models on changes in housing status and its subsequent effects on HIV outcomes for 700 people living with HIV (PLWH) who were unstably housed with co-occurring substance use and psychiatric disorders across 9 demonstration sites in the United States between the years of 2013 and 2017.Methods. Self-reported housing status was collected at baseline, and at 6 and 12 months during the intervention. HIV outcomes included linkage and retention in care, antiretroviral therapy prescription, and viral suppression collected via chart review.Results. In the 12 months after the intervention, 59.6% transitioned to more stable housing. Compared with those who became or remained unstably housed, participants with greater stability achieved significantly higher rates of retention (adjusted odds ratio [AOR] = 2.12; 95% confidence interval [CI] = 1.11, 4.05), were more likely to be prescribed antiretroviral therapy (AOR = 2.06; 95% CI = 1.62, 2.63), and had higher rates of viral suppression (AOR = 1.62; 95% CI = 1.03, 2.55).Conclusions. The use of patient navigators to create a network of services for PLWH who are unstably housed can improve housing stability and lead to improvements in HIV-related outcomes.

Trends in provider-advised HIV antiretroviral therapy deferral in the United States, 2009-2014

Since 2012, U.S. clinical guidelines for antiretroviral therapy (ART) initiation have recommended universal ART prescription barring patient contraindications. Although ART prescription has significantly increased among U.S. HIV patients in recent years, the reasons for this increase, and why some patients are still not taking ART, are not well characterized. To fill these gaps, we analyzed data from the Medical Monitoring Project (MMP), to assess the proportion of persons who reported provider-advised ART deferral during 2009-2014, and used bivariate linear regression to estimate linear trends in provider-advised ART deferral over time by patient characteristics and clinical setting. During this period, the proportion of patients reporting provider-advised ART deferral decreased from 67% to 40%. Significant decreases were observed in all patient subgroups and clinical settings. Patients recently reporting non-provider-advised reasons for ART deferral were significantly less likely to be virally suppressed and more likely to have inconsistent care, be depressed, binge drink, and use illicit drugs. This work suggests that U.S. providers are recommending ART deferral for fewer patients, consistent with increasing adoption of 2012 universal prescribing guidelines. Addressing patients' financial, mental health, and substance use barriers may be needed to achieve universal ART prescription in the United States.

Antiretroviral treatment among commercially insured persons living with HIV in an era of universal treatment in the United States - 2012-2014

In 2012, antiretroviral (ARV) treatment guidelines expanded indications and recommended antiretroviral treatment for all HIV-infected persons in the United States, regardless of CD4 cell count. This analysis describes ARV prescriptions among commercially insured HIV-infected adults from 2012 to 2014. We analyzed persons aged 18-64 years from 2012 to 2014 Truven Health MarketScan Commercial Claims and Encounters® database. We identified HIV-infected persons who had at least one inpatient or two outpatient medical claims and identified pharmacy claims using National Drug Codes. We calculated changes over time in ARV prescription and performed a multivariable regression analysis to examine differences in ARV prescriptions by age, sex, and geographic region. We identified 29,419 HIV-infected persons in 2012, 26,380 in 2013, and 25,414 in 2014. Overall percentage with ARV prescription increased by 7.3%. There was a 23% increase in ARV prescriptions among people new to care and a 6% increase among people already established in care. In 2014, more persons who were new to HIV care did not have an ARV prescription compared to persons established in HIV care (37.5% vs 19.3%, respectively; p  < 0.001). The percentage of persons without an ARV prescription was highest for persons residing in the Northeast (30.8%) compared to those residing in the West (21.7%), North Central (15.9%) and South (16.5%) and was higher among women (26.2%) compared to men (19.5%) (p < 0.001). Uptake of ARV medication has increased since the guidelines expanded their indications in 2012. Despite improvements from 2012 to 2014, a significant proportion of HIV-infected adults with a commercial health insurance plan were not prescribed ARV medications. Insurance-based strategies could be a novel method to increase the percentage of HIV-infected adults who receive optimal care in the United States.

"It's Never Just About the HIV:" HIV Primary Care Providers' Perception of Substance Use in the Era of "Universal" Antiretroviral Medication Treatment

Antiretroviral therapy (ART) is recommended for all people living with HIV (PLWH), regardless of disease status. Substance use disorders (SUD) are common barriers to successful HIV treatment; however, few studies have comprehensively explored how HIV primary care providers take SUDs into account in the context of universal ART implementation. This study uses thematic analysis of qualitative interviews to explore providers' (N = 25) substance use assessment and factors associated with ART initiation. 64% of providers had 15 or more years of HIV treatment experience. Almost all providers agreed with the guidelines for universal ART initiation despite the presence of SUD. Still, identification and management of SUD is challenged by inconsistent assessment, providers' misperceptions about SUD and patients' willingness to discuss it, and lack of accessible treatment resources when SUD is identified. Greater guidance in systematic SUD assessment and management, combined with integrated addiction services, could enhance universal ART implementation among PLWH/SUD.

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014

BACKGROUND

Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART).

METHODS

We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients.

RESULTS

Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years.

CONCLUSION

Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.